Laparoscopic en bloc resection of a persistent pelvic lymph node in cervical cancer after chemoradiation

Abstract

Background: Concurrent chemoradiotherapy (CCRT) is the standard treatment for locally advanced cervical cancer. However, there are still a number of patients who develop persistent disease after definitive CCRT. Surgical salvage remains an option and should be considered, although there could be an increase in technical difficulties and potential injury to the nearby structures. This report demonstrates the laparoscopic technique of en bloc resection of a fixed pelvic node in a patient's irradiated pelvis. Case: A 62-year-old woman with cervical cancer stage IIB underwent concurrent chemoradiotherapy. Post-treatment imaging showed an enlarged left pelvic lymph node below the external iliac vein. An operative finding revealed an intra-abdominal adhesion and an obliterated anatomical plane. The lymph node was resected, using a laparoscopic en bloc technique. Results: After successful completion of the surgery, histopathologic testing of the resected lymph node confirmed that the patient had metastatic squamous-cell carcinoma. Conclusions: According to imaging, the left external iliac vein is used as a landmark to aid in identifying a metastatic node. The surgeon needs to pay attention to the anatomical plane and vascular anatomy. In order to dissect the target lymph node precisely, a small- and fine-tipped-instrument is helpful. Lymph node dissection is facilitated further by pushing the lymph node up gently against the pelvic sidewall. Hydrodissection should be avoided to prevent tumor spillage. Preoperative imaging-guided localization and precise dissection using a fine-tipped instrument are the important keys for accurate and efficient surgery after radiation in these cases. © Mary Ann Liebert, Inc., publishers 2018.